To access and use e-claim form, please CLICK HERE Then enter your user name and password. This would have been provided to you when you hired us. If you have forgotten this information you can call us at 1-800-660-6642.

	A-S Client Number:
	A-S Client Name:
	Debtor First Name:
	Debtor Last Name:
	Debtor Address:
	Debtor City:
	Debtor State:	Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico US Minor Outlying Islands US Virgin Islands Armed Forces Americas (except Canada) Armed Forces Africa/Canada/Europe/Middle East Armed Forces Pacific
	Debtor Zip Code:
	Debtor Phone:
	Debtor FAX:
	Debtor Social Security #:
	Debtor Date of Birth:
	Debtor Occupation:
	Debtor E-mail Address:
	Debtor Name of Employer:
	Debtor Employer Phone:
	Debtor Mail returned from this Address (SKIP)?: yes no
	Debtor Reference #:
	Debtor Spouse's Name:
	Debtor Spouse's Social Security #:
	Debtor Spouse's Employer's Phone:
	Debtor Driver's License#:
	Driver's License State:	Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico US Minor Outlying Islands US Virgin Islands Armed Forces Americas (except Canada) Armed Forces Africa/Canada/Europe/Middle East Armed Forces Pacific
	Verification of Debt: Contract Statement Service Agreement Letter
	Bad Check:	yes no
	Judgment:	yes no
	Signed Contract:	yes no
	Person/Patient Receiving Services:
	Relatives:
	Relatives' Phone:
	Language Spoken by Debtor: English Spanish Other
	Date Debt Incurred:
	Principal Amount Due:
	Valid Collection Fee:
	Valid Interest Charge:
	Valid Bad Check Charge:
	Total Amount Due:
	Late Payment Amount:
	Date (ex.ddmmyy):
	Additional Information (E-mail address, website, where person banks, etc.)